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PLEASE READ
MAX'S PARTNERS WITH PEACE OF MIND DOG RESCUE'S "HELPING PAW PROGRAM" AND CAN SHARE YOUR APPLICATION.
Please wait for a confirmation page to come up to confirm receipt of your application. If you do not see this page, please look for notes about missed fields. If you choose to email documentation to admin@maxshelpingpaws.org rather than uploading through this application, that will delay processing of your application.
CLIENT APPLICATION FOR SUPPORT
How much financial support are you requesting?
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select one
<$500
$500 - $1,000
More than $1,000
Have you applied to Max's Helping Paws for support in the past?
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* Financial assistance has a limit of assistance for one pet/one situation/one family/one-year
select one
Yes
No
Is Pet At Treating Veterinary Practice Now?
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select one
Yes
No
Have you seen a vet yet for this issue?
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select one
Yes
No
Which Veterinary Practice will be doing treatment?
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Application Authorization Code Given To You By Your Treating Veterinarian
Is your financial situation related to COVID-19 job or business loss?
*
select one
Yes
No
Please provide more information about your situation related to COVID-19 or Wildfires
*
Please be specific. Explain how COVID impacted your employment, such as "I worked for a restaurant that had to shut down."
PET INFORMATION
Pet's Name
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Type Of Pet
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select one
Dog
Cat
What Problem Is Your Pet Currently Experiencing and What Treatment is Needed if Known?
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Provide as much detail as possible such as how this illness or injury occurred, why you are applying for assistance. Incomplete information may delay processing.
Where did you get your pet?
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Rescue
Gift from someone
Purchased at store
Purchased from friend
Purchased from stranger
Purchased from Breeder
Found/Stray
Other
How Long Have You Had This Pet?
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select one
Less than 3 months
1-3 Years
3-5 Years
5-7 Years
More than 7 Years
Name Of The Primary Vet Clinic where preventative care is received (And Name Records Are Under)
(If you do not have a regular veterinarian, explain why not here)
Pet's Age
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Pet's Breed or Breeds if Mix
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Pet's Gender
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select one
Male
Female
When Did This Pet Last See A Vet Before this issue arose?
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Is This Pet Current On Rabies And DHPP Vaccines?
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select one
Yes
No
Is This Pet Spayed/Neutered (also referred to as FIXED)
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select one
Yes
No
Why not spayed or neutered?
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select one
Didn't know it was important
No reason
Wanted to breed it
Personal opinions
Too expensive
Never found time
Other
How many other pets are in your home?
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select one
None
1-2
3-4
More than 4
PET OWNER & SPOUSE/PARTNER/PET CO-OWNER INFORMATION
Owner Name (primary applicant)
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First Name
Last Name
Owner's Preferred Phone
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Owner's Email
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Pet Co-Owner/Caretaker Name
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First Name
Last Name
Pet Co-Owner/Caretaker Phone
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Pet Co-Owner/Caretaker Email
Address
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
How Many Adults Including Applicant Are Caring For The Pet At this Address?
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select one
1
2
3
4
How Many Children Under 18 At this Address?
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select one
None
1-2
3-4
More than 4
Check any that apply to primary pet caretaker
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Disabled
Senior (65+)
Veteran
Unemployed/Workers Comp
Active Military
Student
Homeless
Retired
None of the Above
Check any that apply to Pet Co-Owner/Caretaker
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Disabled
Senior (65+)
Veteran
Unemployed/Workers Comp
Active Military
Student
Homeless
Retired
None of the Above
HOUSEHOLD FINANCIAL INFORMATION
Is either pet co-owner or caretaker participants in any low-income-based government program?
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ie CalWorks/CalFresh, CalWater (LIRA),PG&E (REACH)/PG&E (CARE),(CHIP), Disability, Social Security (SSI) or (SSP), AT&T Lifeline, HHS (HEAP), CHISPA, Medi-Cal for Aged and Disabled Covered California Silver Government Programs require proof of participation to be used to meet proof of need requirement
Yes
No
Have You Applied to Care Credit?
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Your application cannot be processed until this is received.
select one
Yes
No
Owner's Employer
Pet Co-Owner/Caretaker's Employer
Do you rent or own your home?
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select one
Rent
Own
Homeless
Other Situation
Monthly Rent Or Mortgage ($)
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Combined Gross Monthly Income For All Pet Owners/Caretakers ($)
*
How much can you contribute to your pet's care? (AMOUNTS ONLY, i.e. 200)
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Who else have you requested financial assistance from or applied to?
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select one
No one
Friends
Family members
POMDR
Other local nonprofit
GoFundMe/Online Fundraiser
Other
Please Let Us Know Anything Else About Your Pet Or Your Situation That Will Help Us Make A Determination About Your Request
DOCUMENTATION/APPLICATION SUPPORT - REQUIRED (ID, PROOF OF FINANCIAL NEED, PET PHOTO)
Upload CLEAR, CLOSE UP photo of your pet (you likely have a bunch!)
*
Ideally LANDSCAPE Orientation (Camera turned on side)
Picture of your driver's license or ID (will be required for processing)
*
You must submit either through form or by sending photo of your ID/DL to admin@maxshelpingpaws.org
Proof of Income or Financial Need
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Can be Paystub, Employer Letter, Bank Account, Tax Return Page, other.
Copy or phone picture of Care Credit results (required for processing)
Your application cannot be processed until this is received, unless you have shown proof of inclusion in a government program. When you apply, TAKE A PHOTO with your phone of the instant decision - otherwise it takes 8-10 days to receive via mail.
Cost Estimate from Treating Veterinarian
File Upload for Proof of COVID IMPACT
(see accepted options noted in application)
File Upload Other documentation required
Proof of Government Program Participation
*
BY SUBMITTING THIS APPLICATION, I CONFIRM I UNDERSTAND AND AGREE TO THE BELOW:
Yes
If I have Care Credit funds, I may be asked to use some available credit towards the pet's treatment unless I show documentable proof of need to use it elsewhere.
Pets that receive MHPF funding must be spayed or neutered unless medically not advised or other approved reason. If my pet is not spayed/neutered at the time funding is given, I agree to have my pet spayed/neutered within 90 days.
I provide consent for MHPF to share my application in order to secure additional funding in connection with my request for financial assistance from MHPF
I agree to allow MHPF to interview me and will share photos and videos to be used for fundraising purposes. Follow-up after recovery is a requirement of this grant.
I consent to use of my pet’s name, image & story by MHPF for website, PR, and other marketing purposes, AND I will cooperate with MHPF to schedule photos, interviews or video as necessary for their use.
Owner "Signature" (Type Name)
*
